Provider Demographics
NPI:1376698290
Name:WALLIS, GREGORY SCOTT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:SCOTT
Last Name:WALLIS
Suffix:
Gender:M
Credentials:CRNA
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Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:106 COUNTY ROAD 253
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-6980
Mailing Address - Country:US
Mailing Address - Phone:936-554-7297
Mailing Address - Fax:
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-568-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered